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 Cross-Canada Forum An integrated exploration into the social and environmental determinants of health: the Saskatchewan Population Health and Evaluation Research Unit (SPHERU)
Ronald Labonte, Nazeem Muhajarine, Sylvia Abonyi, Georgia Bell Woodard, Bonnie Jeffery, George Maslany, Michael McCubbin and Allison Williams Abstract The Saskatchewan Population Health and Evaluation Research Unit (SPHERU) is a new interdisciplinary research institute established by the Universities of Saskatchewan and Regina. SPHERU developed four of its research programs using a hierarchic model of health determining conditions and contexts. In descending order these programs include:
A fifth program researching the determinants of health of indigenous peoples spans all four levels. Two research projects, one on power, control and health, and another on community capacity building approaches to human service programs, assist SPHERU in developing the theoretical linkages between its programs. This article describes SPHERU's research model and the Unit's approach to research and summarizes each of its current research programs and projects. Key words: interdisciplinary research; population health; population health conceptual models
Introduction The Saskatchewan Population Health and Evaluation Research Unit (SPHERU) is a newly established (1999) non-profit research institute. It is governed by a board of representatives of the universities of Saskatchewan and Regina and three other founding partners, Saskatchewan Health, the Saskatchewan Association of Health Organizations and the Health Services Utilization and Research Commission. Ronald Labonte was hired as its first Director in late 1999. The first group of multidisciplinary researchers was hired in July of 2000. Since then, SPHERU has developed five different research programs and several research projects, obtained research funding from several national and provincial research agencies and begun to establish itself as a "new" Canadian focal point for health research. This article is written to introduce health researchers and policy makers to SPHERU, its approach to research, its developing research programs and some of its current activities. We would like to describe our deliberative strategy to be interdisciplinary, integrated and theoretically linked in all of our research, and to invite collaborations with researchers or other stakeholder organizations, groups or individuals interested in our programs of study. Mission statement All new organizations begin by framing a broad goal, or mission, for their work. SPHERU's mission is
This lofty intent can be distilled into simpler language. Decades of past research identify the primacy of our social and environmental conditions in influencing our health and well-being. SPHERU's interests lie in better explaining how these different living conditions affect different health outcomes for different people in different places. We are interested in the how so that we might be better able to identify the what, in terms of policy options. We want our research findings to be relevant to policy decision-makers. This means working closely with policy makers in framing our research and ensuring that each study incorporates a policy analysis component. We include several policy makers as co-investigators in our research, and others sit as members of our Board of Directors. That's a healthy start. We are aware that policy making is more than just a matter of providing relevant research findings to government bureaucrats and elected officials. It is about politics. As one current phrase expresses, "We do not yet have evidence-based policy making so much as policy-based evidence making". Many of the most important determinants of population health are embedded in economic, social and political structures of inequality. Remedial policies that reduce these inequalities face an uphill battle, so to speak. Part of the force that pushes these policy options up into the political arena of decision-making is civil society and its many organizations. Another principal underlying our mission statement, then, is working closely with community constituencies to ensure that we are asking the right questions, and that there is an organized public interested in the answers. Finally, both policy makers and an organized public require assistance in untangling the messy web of population health determinants. We regard making research expertise accessible to the public, especially as it applies to understanding the strengths and limitations of specific research findings, as an important moral, as well as practical, obligation. Our public communication must be clear, concise and understandable. It is not enough for research to fill the pages of journals or advance the academic careers of researchers. SPHERU's research model Population health research covers a vast potential territory. To help us map this territory, SPHERU developed the simple model representing broadly defined categories of health determining conditions. (Figure 1). Each of these categories (or levels) can be studied as a separate health determinant. Unlike other similar models, however, we do not portray them as different bands of a rainbow. Each affects the others, so they "touch" not only on health, but also on every other level or "band" in our model. Better understanding the health impacts of the relationships between the levels is as important as understanding the health impacts of each level by itself. The overarching level is that of our ecosystem. Without a healthy planet, nothing else matters. Environmental health is not yet an integral part of SPHERU research, but we intend to have it become so in the future. The next level is that of market/state relationships. Economic activities are based on production and consumption, increasingly global in scale. There are limits to this, which our planet and societies now face. We need to produce and to consume to be healthy, but produce and consume how much? Produce and consume what? How fairly? These are questions of public policy and governance. They are also central to the SPHERU research program on Economic and Environmental Globalization, Governance and Health, which incorporates a global environmental perspective in its research. An overview of each of our programs follows later in this article. Below the broad sweep of market/state relations lies that of community (both geography or neighbourhood and affinity or interest) and discourse (peoples' cultural or other belief systems). Some belief systems dominate others, partly due to economic and power differences in the level above. But dominant beliefs are also challenged by local actions and, increasingly, linked actions by communities of affinity that stretch around the planet. What mix of beliefs, what balance of diversity with consensus, what local programs, services and structures, create the greatest equity in health for people? These questions are integrated within the Community/Environment as a Health Determinant research program. The next level down describes the intersection between these local phenomena and our personal and family health. How we regard ourselves, our ability to think critically and to feel competent, the quality of our social relationships, our individual habits - these are all powerful mediators between conditions in our environment and our health and well-being. The community/family nexus is a primary focus for our research program on Multiple Roles, Gender and Health. Finally, our personal health is influenced by our biological makeup (still largely unmodifiable, and with no certainty how much that might change in the future) and by our family experiences. Early childhood is increasingly seen as an important time when our health futures are at least partially embedded in our biologies. But what are the community, as well as familial, determinants of healthy childhood? And how do cumulative experiences over time mitigate less healthy starts to life? Our final "hierarchic" research program, then, focuses on the Determinants of Healthy Childhood Development. SPHERU is also developing a fifth program on Indigenous People's Health that cuts through all of these levels. Our model also contains a few basic assumptions:
These assumptions are open to empirical refute. For the moment, however, they shape our intention to explore the "determinants" of health determining conditions as broadly and as thoroughly as possible. Linking theories SPHERU is attempting to link all of its research theoretically. Three theories (actually, categories of theories) are presently being used.
Capacity building: the role of social networks, economic activities, services, programs and research itself to build local ability to sustain health; and Power: the role of social and psychological power relations in creating health, and in building capacity and ensuring participatory democracy. Two research projects, in addition to our programs, are developing our knowledge in these theoretical areas. 1. Capacity building This research project, under the banner of the University of Saskatchewan "In Motion Community Alliance for Health Research", seeks to understand community capacity building as a generic strategy for population health. Capacity building is based on equity, empowerment, and participation and works to strengthen communities, whether grassroots, inter-organizational partnerships, or networks of agencies, to organize and act to achieve their goals. Capacity building is a means to the end of program specific health goals. But health programs can also be a means to develop capacity building as a health-enhancing end in itself. 2. Power, control and health This research project currently studies the life-long interactions among social, community and psychological factors such as powerlessness, sense of control, learned helplessness and empowerment, as power-related issues. It investigates the role and impact of powerlessness in producing various health and health-risk factor outcomes. It applies this knowledge within the mental health area to improve the empowerment capacity of interventions, and the evaluation of interventions as both empowering and likely to produce mental health benefits for that reason. We hope that this empirical work will assist the Unit in better theorizing and examining how power functions as mediating phenomenon between well known differences in health outcomes and socio-economic status. FIGURE 1
SPHERU's research programs SPHERU has organized its research under five broad program areas, the first four of which correspond to different levels in our model (Figure 1). These are
Each of these is described briefly below. 1. Economic and Environmental Globalization, Governance and Health This program studies the relationship between economic globalization and population health. Studies examine the direct and indirect effects of trade and investment volumes and policies on key health-determining conditions, regulatory capacities, trade in health-damaging products and access/quality of health-promoting public services. A simple model describes the potential pathways linking recent globalization to health and quality of life (Figure 2).
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FIGURE 2
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Key research questions How is globalization affecting socio-economic, environmental and governance "pathways" to health? How are current trade and investment agreements specifically affecting health-determining pathways? How should trade and investment agreements be amended so that there are absolute and relative improvements in global health? Examples of current activities
2. Community/Environment as a Health Determinant This program focuses on the pathways and processes by which "community" operates as a direct influence on health and overall quality of life. We know that both the social and physical environments affect health, but we don't fully understand the mechanisms through which this happens. One of the most important research needs in health inequalities scholarship is to clarify the pathways through which differences in socio-economic status are manifested in everyday life, and produce, at the aggregate or community level, the systematic social gradient in health observed in most countries of the world. Key research questions How do the physical and environmental characteristics of communities cause ill health, or protect and enhance good health? What health effects result from inequalities in the physical characteristics (e.g., public parks, population density) of the community? How do communities' socio-economic characteristics (e.g., income, education, degree of ethnic diversity) cause ill health, or protect and enhance good health? What health effects result from the inequalities in socio-economic characteristics (e.g., income, education) of the community? Many of these community-level determinants are linked to the effects of globalization on national, provincial and local public policies, such as provision of public services or goods, income redistribution, environmental protection and so on. Examples of current activities
3. Multiple Roles, Gender and Health This research program examines socio-economic status, role occupancy, and social relationships as pathways to health status. Social roles have changed dramatically in recent decades, but knowledge of their health effects (e.g., role-strain or role-enhancement), and the modifiable social or workplace policies that influence these effects, is still incomplete. Key research questions How do different social roles (role patterns) interact to create health or illness? What personal and social resources, both outside and inside the workplace, mediate health effects arising from high demand circumstances and occupying multiple roles? How do social role pathways differ for women and men, and for First Nations/Aboriginal peoples? How do social role pathways of parents influence the health of children? The last two questions directly link this program of study to examining the upward impacts of community-level determinants, and the downward effects on child and family health. Examples of current activities
4. Determinants of Healthy Childhood Development This research program attempts to understand how specific factors within and between various levels of environment (prenatal, family/home, community, and global) influence children's health and well-being. Key research questions What interventions during the prenatal period are effective in breaking the intergenerational transmission of risk? Why do children living within a specific array of family and community characteristics do better than other children in their preparedness for lifelong learning? What are the effects of changing family relations and role expectations on children's lives? What specific community and intersectoral partnership strategies and government policies for serving children and their families are most effective in enhancing children's health and positively changing the key determinants of children's health? The questions posed start at an individual level, and examine the pathways upward through role relationships, to community resources, to public policy and globalizing forces. Examples of current activities
5. Indigenous Peoples' Health This research program studies health determinants in indigenous populations and is being developed in full collaboration with First Nations/Aboriginal communities and organizations. The program intersects with all other SPHERU research areas. It also stands alone however, attempting to consider where and how health-determining conditions are affecting positive outcomes for First Nations/Aboriginal communities, despite health-damaging historical and contemporary circumstances. Key research questions Under what conditions are some First Nations/Aboriginal people/communities doing well? How do people create meaningful and rewarding socio-cultural environments? Which programs and policies on health determining conditions are facilitating positive health outcomes? Examples of current activities
SPHERU's research faculty SPHERU will be able to support nine full-time researchers. We presently have five, plus two research fellows and a half-time associate director. SPHERU deliberately and uniquely seeks to recruit people representing different disciplines and different research methodologies. Most of our research applications and programs are developed collaboratively. We have already learned a tremendous amount from each other in sharing our discipline-specific orientations to the same set of research problems or questions. Table 1 identifies our present faculty, the research program in which they are "lead" investigators, and their discipline backgrounds. Population health determinants may be influenced by policies residing within boundaries, but they also transcend place. For this reason, we are already working with over 20 researchers from different universities in Canada and abroad. We encourage readers who, based on this brief synopsis of our approach and programs, may be interested in future collaborations, to contact the corresponding author (Ronald Labonte). For more information on SPHERU, visit our web site at: <www.spheru.ca.>
TABLE 1
Author References Ronald Labonte, Community Health and Epidemiology, University of Saskatchewan, and Faculty of Kinesiology and Health Studies, University of Regina Nazeem Muhajarine, Sylvia Abonyi, Community Health and Epidemiology, University of Saskatchewan Georgia Bell Woodard, SPHERU, University of Saskatchewan Bonnie Jeffery, George Maslany, Faculty of Social Work, University of Regina Michael McCubbin, SPHERU, University of Regina Allison Williams, Department of Geography, University of Saskatchewan Correspondence: Ronald Labonte, Community Health and Epidemiology, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan S7N 5E5; Fax: (306) 922-7920; E-mail: ronald.labonte@usask.ca
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Last Updated: 2002-06-20 |  |
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